01/28/2012

Perioperative communication barriers to effectivecommunication

Perioperative communication barriers to effectivecommunication,Business Lessons from Lady Gaga10 tips on how to apply the pop stars impressive business wisdom to your own small business.

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--understand the need to use only accepted terminology in records.

The receiver

Passing on these messages often involves the team leader in delegating responsibility to a competent member of junior staff. If information is to be communicated effectively through more than two people, the message must be clear, concise, timely and fitting (Taylor & Campbell 1999). Increasing the number of people involved in sending a message increases the chance that a misunderstanding will be introduced.

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General Medical Council 2006 Good Medical Practice London, GMC

Patient Care: Knowing and Doing

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The message--the information itself and the form it is being transmitted: written communication, verbal communication and unconscioussigns or signals.

The responsibility of the sender of any important message is to consider the information they wish to share with another. Before communicating the message they should consider how they will assess that the recipient has understood what has been transmitted. They should also select the most effective form of information sharing to avoid errors or misunderstandings. For example, if during surgery, the operating surgeon asks for the specimen to be sent for histology-they should ensure the clarity of the message is clear and that the perioperativepractitioner understands the request. The most effective way of communicating information about the specimen might be to inform the perioperative practitioner of the nature of the specimen (in this case thepatients appendix), and then provide further instructions on how itshould be prepared for histology (for example by insertion in formalin) before dispatch to histology.

Most doctors work in teams with colleagues from other professions. Working in teams does not change your personal accountability for your professional conduct and the care you provide. When working in a team, you should act as a positive role model and try to motivate andinspire your colleagues. You must: communicate effectively with colleagues within and outside the team. (Para 41-42)

As a perioperative practitioner it is important that we grasp and develop skills that support effective communication with all members of the operating team. This creates challenges for many but accordingto Seed (2006) reflection-on-action can aid with effective communication. Her experiences led her to reflect on an event where a non-English speaking patient entered the anaesthetic room accompanied by her son. This led to inappropriate use of the relative as an interpreter.In turn this led to complex issues being raised about the consent process, breaches of patient confidentiality and confusions which led to the change of a local to a general anaesthetic. Her conclusion highlighted how she has become more aware of her practice and that communication with ward and surgical colleagues is essential in providing timely patient care. Effective communication is the responsibility of all working in the health service and should be a dominant feature inthe organisations culture.

The receiver--the person who has received the intended transmission of information.

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Many writers refer to feedback as the recipbarriers to effectivecommunicationients reaction to whathas been conveyed. Feedback may not always be a conscious and thought through reaction. During tense and pressurised surgical events feedback may be clouded by emotional ctors. Complex or critical surgerymay demand the surgeon to be extremely focused on the operative field and this might cause the surgeons attitude and degree of courtesy to ll below acceptable standards. This sort of behaviour is hard toexcuse but easy to understand. In these frequently fraught circumstances it is even more essential that communications are checked and verified.

The communication of a message with clear meaning can be complicated by the attitude of the sender and perhaps the circumstances of itscommunication. In the example above, the significance of the messagemay be distorted by the pressure of the surgical events: severe bleeding at the operating site may cause fear and confusion among all concerned. In such an event it is the responsibility of both the sender and receiver of the message to check clarity and understanding at themost apt moment. Where the message is written, the sender should consider the way they have expressed the message and how it might be interpreted. Accurate interpretation of written communication is often through unambiguous expressions and clear expectations of the purpose of the information.

Any intended messages should be carefully constructed and written in a clear and concise manner. The message should be written in such a way that action can be taken immediately. However, all perioperative staff will be aware of occasions where written messages are ambiguous and raise further, confused communication and feedback until a shared understanding emerges. Clarity in written communication is of theutmost importance in the induction of new staff to operating departments. Policies, procedures and practices should be clearly written ifjunior staff are to be expected to observe them. The purpose of written policies in perioperative departments is often misunderstood. Thepurpose of a policy is to guide staff in safe working and to ensure that staff work to the same standard. They act as a point of reference and teaching aid for new and experienced perioperative practitioners. They are derived from national guidelines and from such sources asthe Department of Health and the National Confidential Enquiry into Patient Outcome and Deaths. Local interpretations of guidelines have a degree of flexibility to take account of local requirements.

Where might you or your department improve your service to avoid some of the Bristol mistakes in communication?

Bristol Royal Infirmary Inquiry 2001: The inquiry into the management and care of children receiving complex heart surgery at the Bristol Royal Infirmary. Crown Copyright. Available at /final_report/Summary.pdf

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In one of her speeches, Ann Abraham, the health service ombudsman,stated that many NHS complaints resulted from poor communication. She states:

For the general public, who may understand little of the technicalaspects of care, the quality of communication and the quality of care are intimately linked. Therefore high quality communication is a key priority in gaining public confidence. This is of the utmost importance to all of the practitioners involved as well as their respectiveregulators. The importance that good communication is given by the professions is reflected in the place the subject occupies and in the professional codes of practitioners. Accordingly, the doctor, the registered nurse or the midwife will find that all forms of communication are within their field of responsibility including verbal, nonverbal or written forms.

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KEYWORDS Effective communication / Perioperative communication

What methods of communication do you use for communicating formal information?

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Verbal communication is the most common means by which staff communicate with each other in perioperative settings. This can consist ofce to ce communication where words are supplemented by cial movements and gestures both of which enrich the message. Verbal communication is also a component in day-to-day telephone conversations which form a key part of interdepartmental communication. Here, voice inflection and tone will supplement the verbal content of messages. An example of verbal communication might be the ordering of special equipment for unusual operating lists, or the ordering of non standard equipment from the sterile stores department.

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In many perioperative settings written communications are situatedin such areas as the communication book, the communication board, the checklist, the theatre register, the staffing rota or the off duty.

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--be able to keep accurate, legible records and recognise the needto handle these records and all other information in accordance withapplicable legislation, protocols and guidelines

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You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been.

Occasionally, this type of process ils because of habitual custom and practice approaches to the organisation of perioperative work. Where a perioperative team has worked together for some time, taskscan easily be performed by rote without specific demands being voiced. Indeed it is the mark of the experienced scrub practitioner to be able to stay one step ahead of the surgeon and to anticipate requirements without being asked. The benefits of this can be a smooth and efficient operating list. However in some instances, errors occur from misinterpretation or from a lack of communication about special or exceptional circumstances.

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Kennedy I 2001 Bristol Royal Infirmary Inquiry. The inquiry into the management and care of children receiving complex heart surgery atthe Bristol Royal Infirmary. Crown Copyright. Available at / final_report /Summary.pdf

Helmreich RL 2000 On error management: lessons from aviation British Medical Journal 320 7237 781-785 Kennedy I 2001 Bristol Royal Infirmary Inquiry: The inquiry into the management and care of children receiving complex heart surgery at the Bristol Royal Infirmary. Crown Copyright. Available from: /Summary.pdf [Accessed May 2009]

The ODP must:

1b.2 be able to contribute effectively to work undertaken as part of a multi-disciplinary team--be able to use effective communication skills when sharing information about patients with other members of the multi-disciplinary team

Castledine (1998) reminded us that communication is about the conscious transmission of information between parties. Yet frequently what one party means to say is not heard by the party who is meant to listen. At the outset of our discussion therefore it is worth stating bluntly that the practitioner should adopt the practice of checking communications for accuracy, understanding and meaning among those withwhom we wish to communicate. Taylor and Campbell (1999) point correctly to the ct that effective communication starts with the individual understanding the communication process. This involves listening and questioning, it involves assessing the degree to which what is intended to be transmitted is actually what is being received.

According to Davies (2005) when poor communication or associated problems occur for the perioperative team it is usually across the multi-professional groups. For example, transmitting information betweenthe anaesthetist, surgeon and allied professional is often the root source of the problem. Different professional cultures, terminology, and exaggerated respect for others often gets in the way of effectivecommunication. Davies (2005) states that there has to be mutual respect among team-mates to provide a conduit for effective communication to take place. Importantly, Dimond (2002) reminds us also that it is possible for a negligence case to arise where a professional has iled to communicate with the correct person at the correct time and in the proper way.

The responsibility of effective communication lies with the individual practitioner first and foremost. To prevent poor communication taking place, they should ensure that they have the correct skills to communicate effectively, be that by listening, reflecting on experiences or writing.

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Summary

Have you been involved in a patient case where poor communication was noted?

Written communication

There are numerous ways in which patient relevant information can be communicated among staff from differing professions in the perioperative setting. What unites them all is the desire to ensure that theappropriate treatment is delivered and that the experience of surgery is as acceptable as possible to the patient.

Indeed the inquiry explained how poor communication contributed towards the deaths of twenty-nine babies receiving heart surgery. Although communication was not the main cause of the incidents it was implied that the risks could have been reduced through effective communication (Kennedy 2001).

Within the perioperative environment several written examples of communication are necessary for the protection of the patient and to demonstrate that our duty of care has been fulfilled. The most notableand essential of these written communications is the patients consent form. The information provided on the consent form informs the perioperative team about the patients identity and the operPerioperative communication barriers to effectivecommunicationation they have agreed to undergo. It goes without saying that this most basic ofwritten communications should be legible, accurate and checked following patient safeguard procedures.

The person receiving the information has the duty to ensure that they have understood the meaning and any action associated with the information. It is good practice for practitioners to indicate that they have understood the communication. This will confirm that the message is clear, that the intended meaning has been grasped and that understanding has taken place.

2b.5 be able to maintain records appropriately

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Association of Anaesthetists of Great Britain and Ireland 2004 Checking anaesthetic equipment Available from: / guidelines/docs/checking04.pdf [Accessed March 2009]

You must ensure any entries you make in someones records are clearly and legibly signed, dated and timed.

The message

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Occasionally the work of outstanding departments can be tarnished by lurid press reports where mistakes arising from poor communicationhave led to catastrophic results. In these instances it is often thecase that a sequence of circumstances has produced the setting in which a communication ilure leads to disaster. Only when all of the unsafe circumstances align does the catastrophe occur. This model of causation, postulated by psychologist James Reason, has been describedas the Swiss Cheese model (Reason 2000). While this model of causation might be of some psychological relief to the person whose poor communication led to tragic events, it is less clear that it would be accepted by colleagues and managers who might feel that blame is being spread inappropriately.

You must ensure any entries you make in someones electronic records are clearly attributable to you. Similarly, the Health Professions Council (HPC 2008) clearly states that it is the responsibility of an operating department practitioner (ODP) to ensure that effectivecommunication occurs when delivering patient care.

There is little doubt that the general public have high expectations of the UK health service. Effective communication is a responsibility placed on all perioperative practitioners as they attempt to provide safe, efficacious and palatable care to patients. Poor communication can and does lead to some situations where those expectations arenot met. The result of this can be an accusation of negligence resulting from a tragic error. The Bristol Royal Infirmary Inquiry Report commented on communications in this way:

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Task 4

The sender

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Communication has always been a key aspect of effective perioperative care. Operating departments continually attempt to improve communication between all parties in the perioperative setting, and articles on this subject are common in professional publications. However itis also true that examples of bad communication abound. In one studywhich examined communication during 48 operative procedures, a totalof 421 communication events produced 129 instances of communicationilure (Lingard et al 2004). Sometimes these ilings have severe consequences on the patient, the trust and the practitioner. Lessons in error management drawn from high risk areas of healthcare such as operating theatre practice have been derived from aviation and aircraft incidents. Frequently, errors will have similar root causes. Psychologist Robert L Helmreich has argued that one of the main parallel areas of error generation is flawed communication. He cites his own studies which show that, in one hospital under review, two thirds of doctors and nurses quoted better communication as being the most useful way of reducing errors (Helmreich 2000).

This article has raised the issue of effective communication within the perioperative setting. There are many methods for sending information from one person to another. Most important in effective communication is the clarity of the message and how practitioners check that the recipient understands the intended point. If key aspects in thecommunication process are not fully understood or utilised, then we subject our patient and our colleagues to potential risk. If poor communication causes untoward and unacceptable consequences then the perioperative practitioner will be accountable for their actions in law and to their regulatory body.

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Introduction

Non-verbal communication plays a part during operating lists. Communication during a surgical procedure is mostly formal with the surgeon requesting instruments, swabs and sutures at different stages of their work. However non-verbal communication might involve the surgeonrequesting instruments with hand signals for different instruments; opening and closing of fingers to imply scissors for example. In modern surgery, although some surgeons may use hand signals it is considered best practice to ask for the instrument by name. This avoids confusion and unnecessary delays in surgical procedures. During surgical procedures, distractions should be kept to a minimum to provide the most comfortable ambient operating conditions for the surgeon althoughthere is evidence to suggest that there is considerable background chatting in operating departments (Undre et al 2007). Taking this intoaccount, circulating staff can anticipate the scrub practitioners needs by knowing the operation and the surgeons preferences. Using this knowledge can enable circulating staff to offer surgical items without verbal exchange. Where the circulating practitioners become aware of heavy swab use during surgery, unopened replacements can be gathered without a formal request having to be made. Where the need for swabs is less urgent the scrub practitioner may use a gesture of holding up a clean swab to signal that they would like more. This demonstrates that non-verbal communication can work effectively and still contribute to the smooth running of an operating list.

The General Medical Council document Good Medical Practice (GMC 2006) is explicit about doctors responsibility in communication:

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Nursing and Midwifery Council 2008 The Code: Standards of conduct,performance and ethics for nurses and midwives. Available at org/aArticle.aspx?ArticleID=3056

How might the barriers be overcome?

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One of the other important areas for communication to occur is in the delivery of anaesthesia. Checking of equipment as recommended by the Association of Anaesthetists in Great Britain and Ireland (AAGBI 2004) should be recorded for each patient. It is imperative that those records are easy to read and understand, and that they demonstrate what equipment was used for each patients treatment. To make this task easier, this information is often recorded on pre-printed forms, similar to consent forms. Pre-printed forms assist with minimising anymisinterpretation of the data inserted by the perioperative practitioner.

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If only all health service staff made sure that they listened to patients and their carers, communicated clearly with them and with each other, then made a note of what had been said, the scope for latermisunderstanding and dispute would be reduced enormously. (Pincock 2004)

The communication process has four main elements:

Did the poor communication result in an error or incident? How canit be avoided?

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Despite the practitioners professional obligation to deliver carewhich derives from clear, precise and humane communication, mistakesstill occur, sometimes with tragic results. The purpose of this article is, therefore, to revisit the legal, moral and human aspects of communication within perioperative care. It is also an invitation to the reader of whatever discipline, to reflect upon their own standardsof communication in the provision of perioperative care. This is a field in which we all have something to learn.

In the perioperative setting the communication book has been used to share valuable information about ordering of equipment, staffingrequests, problems associated with specimens and other aspects. Thisform of communication provides continuity in the use and running of the service. As many operating departments do not close and are open over a twenty-four hour cycle for emergency cases, then the communication book forms the connection between day, evening and night staff.

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Barriers to effective communication are common in the perioperative setting and we should spare no effort to remove them. A common source of errors is the lack of clear enunciation of instructions. The receiver of the message might not hear clearly what is said, and the presence of a ce mask will deprive the receiver of visual cues which can be observed by lip reading. However it might also be that the junior member of staff who has been delegated to take a message lacks confidence and mumbles a semi comprehended instruction. The receivers feedback is important in this situation. Courteous clarification ofthe initial message will arrest the transmission of this error, as will the clear expression of the sender.

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You must not tamper with original records in any way.

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Read the following and answer the question.

The feedback--the reaction to the received information.

Nursing and Midwifery Council 2008 The Code: Standards of conduct,performance and ethics for nurses and midwives. Available from: [Accessed May 2009]